Auto Accident Form

Please complete the form on this page to send your information to our clinic.

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Step 1 of 9

Personal Information

Name*

First Last

Social Security #

Home Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Fax #

Cell Phone*

Birth Date*

Marital Status

Single

Married

Divorced

Widowed

Ocuppation

Employer

Office Phone

Employers Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Spouse's Name

Number of Children

Names & Ages of Children

Emergency Contact

Emergency Contact's Phone #

How were you referred to our office?

Family Medical Doctor

Permissions

When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office?

Yes

AUTHORIZATION AND RELEASE: I authorize payment of automobile insurance benefits directly to the chiropractor or naturopathic office. I authorize the doctor(s) to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this Active Lifestyle Clinic to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

The following person(s) have my permission to receive my personal health information:

Patient's Name*

First Last

Date

Guardian's Name Authorizing Care

First Last

Date

Informed Consent*

I understand and consent to the following terms:

Chiropractic Care:
I will use my hands or a mechanical instrument upon your body in such a way as to move your joints. This procedure is referred to as "Spinal Adjustment." As the joints in your spine are moved, you may experience a "pop" as part of the process.

There are certain, rare complications that can occur as a result of a spinal manipulation. These compilations include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, strains and dislocations, costovertebral strains and separation. Extremely rare complications include, but are not limited to stroke or fracture. The most common complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment.

Physical Therapy:
I understand that the exercises and myofascial release I receive is provided for relief of muscular tension and pain. If I experience any discomfort, I will immediately inform the therapist so that the pressure can be adjusted to my level of comfort. I agree to keep the therapist updated to any changes in my health and understand that there shall be no liability on the therapist's part if I fail to do so.

Naturopathic Care:
I understand that all injection treatments are accompanied by possible risks. Risks include bruising, temporary increase in pain, inflammation, infection, allergic reaction, numbness, weakness or paralysis, spinal headache, lung puncture or death as a result of, or in relation to the injections.

Injections may include nerve blocks, Intravenous therapies, trigger blocks, intramuscular injections, scar therapy, joint/tendon/ligament injections, or prolotherapy.

I understand that insurance reimbursement for injections varies and that prolotherapy may be considered investigational or experimental by some carriers or Medicare.

I am aware of all of the above mentioned complications for each therapy I may receive, and in order to minimize their occurrence I will take precautions. I have been given the opportunity to discuss the nature and purpose of all treatments in this office, alternative methods of treatment, risks and complications associated with them. I acknowledge that all my questions have been answered to my satisfaction and that I have been further told that any additional questions I may have will be answered.

If my child is a minor, I have given consent for him/her to receive the necessary care in this clinic according to this consent.

Name*

First Last

Date

Signature*

Healthcare Services Contract

Welcome to Dr. Winton’s office, integrative health care for the body and mind. This document contains important information about professional services and business practices. Please read it carefully and ask any questions you have about the information. Naturopathic Medicine requires an active effort on your part, and in order to be successful, you will need to be willing to make certain lifestyle, behavioral, and/or dietary changes. Naturopathic Medicine takes a comprehensive approach to wellness, focusing on the body, mind, and spirit. Naturopathic medicine can be very effective in treating both acute and chronic illness and is preventative in nature. Your initial visit is an information gathering session that allows the physician to better evaluate your health care needs and appropriate therapeutic treatments. If you have any questions or concerns, please let the doctor know at your initial visit, so they may be addressed immediately.

Confidentiality

Information regarding your treatment will not be released without your written permission except in the following circumstances, which are mandated by law. 1.) If you threaten grave bodily harm to another person or yourself, I am required to inform the intended victim, and appropriate law enforcement agency, family members or others who can provide protection, I am under legal obligation to warn and protect. 2.) I must report actual or suspected abuse to children, the elderly, or the disabled. 3.) I must comply when a report is ordered by a Court of Law Please be aware that insurance health care plans may involve direct clinical management by the insurance company and may have some impact on confidentiality. Please refer to HIPPA notice of privacy practices for more information regarding how your personal health information is utilized.

Natural Substances

If I am given the opportunity to purchase any substance or device from Dr. Winton, I understand that this is a natural substance or device, which may be filled by another doctor of naturopathic medicine or by a pharmacy of my choice. Furthermore, I understand that I am under no obligation to purchase any natural substance or device from Dr. Winton.

Emergencies

I understand that if I have an urgent medical condition, and I am unable to reach Dr. Winton directly, at 480-704-1050, it is my responsibility to seek appropriate medical care. I further understand that if there is a medical emergency or serious medical concern, I am to call 911 immediately

Consent to Treatment

I authorize Dr. Winton to administer treatment and perform such general procedures, as he deems therapeutically necessary in the diagnosis and treatment of my condition. I understand that no guarantee or assurance has been made as to the results that may be obtained from such treatment. I understand that Dr. Winton intends to provide top quality care. However, if I am unhappy with services I received, I intend to immediately tell Dr. Winton and/or his staff, so that my concerns/complaints can be addressed immediately. If I am pleased with my care, I have the option of referring my friends and family. I have read this form and agree to all its contents with my signature below.

Insurance

In the state of Arizona Naturopathic Medical Doctors are not covered by Insurance at the time of service. We provide our patients with billing sheets which have diagnosis codes and procedure codes for the patient to submit directly to their insurance company for reimbursement. It is up to your insurance company to decide whether to reimburse you for your visit and the amount they will cover. We do however accept health savings and flex spending accounts to cover all your treatment services and supplement purchases at our office. We provide you with a lab order to have your blood drawn at an outside lab (Sonora Quest or LabCorp) for insurance to cover.

Arbitration

I understand that this is a patient directed therapy and I am directing Dr. J Todd Winton to perform the procedure(s) necessary to restore my health and that in doing so I, and any and all parties that may represent me or my estate, hold harmless the staff and all other controlling or involved entities or manufacturers. In the event of a dispute, I and/or my above representative parties agree to binding arbitration that follows the rules of the American Arbitration Association.

Cancelation Notice

I understand that if I am unable to keep my appointment that I will give a 24 hour notice or I will be subject to either a penalty of $35 or the cost of that service, whichever is less.

Refunds

Any refunds on packages will be reimbursed at the standard rate.

Patient Name*

First Last

Date

Signature*

Authorization & Release

The patient understands and agrees to allow this medical office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

The following person(s) have my permission to receive my personal health information:

Patient Name*

First Last

Date

Guardian's Name Authorizing Care

First Last

Date

Notice and Claim of Health Care Provider Lien

Dear Patient,

It has become standard practice in the Health Care Industry and a requirement of the State of Arizona per Statute 33-931 and 33-932 to file what is known as “Notice and Claim of Health Care Provider Lien”. These liens must be recorded with the County Recorder’s Office, by law. A copy will be sent to you for your records and will be released when we receive payment in full.

Please be assured that this is not a lien against you, or your property. This is not a reflection on your integrity and will not be picked up by credit reporting agencies for any reason, as this lien is not against you the patient, but merely a lien for payment from the responsible insurance company for your medical care costs.

At the time of settlement of your case you may receive a check/draft made out jointly to you and the Doctor, at which time you are required to promptly bring the check/draft to our office for disbursement of funds.

If you have an attorney, the check may be made out to you and your attorney. Your attorney must sign an indemnifying agreement with the insurance company to pay any and all liens in full (we do not typically negotiate to reduce our fees). If for some reason your settlement does not cover the cost of your care, you are personally responsible and agree to pay the balance of the bill in full.

Patient's Name*

First Last

Date

Filing Healthcare Provider Lien

Drs. Todd and Jennifer Winton Active Lifestyle Clinic 16515 S. 40th St. Suite 131 Phoenix, AZ 85048 Phone: 480-704-1050 Fax: 480-704-0109

Patient Information

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Loss

Date of 1st Treatment

Where accident occurred

Time of Day

County where accident occurred

$ Amount for all treatments to-date

Continuing care?

Med-Pay Information

Insurance Company Name

Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claim Number

Policy Number

Insured

Adjuster

Third Party Information

Insurance Company Name

Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claim Number

Policy Number

Insured

Adjuster

Attorney Information

Firm Name

Attorney's Name

Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Our Policy Regarding Cancelations

We respect our patient's time. It is important that each patient be on time so as not to take up time from other patients. If you are late, full payment is required even though you will receive only the remaining portion of your visit. If you are unable to keep your appointment, we will be happy to reschedule you. However, 24 hours notice is required or a $35 fee will be automatically charged to your credit card on the date of your missed appointment. This charge is non-refundable. This applies to all visits for naturopathic medicine, physical therapy and massage. Chiropractic visits will not assess a fee unless excessive visits are missed. Automobile accident patients, who normally have the payment covered by their respective responsible parties, will be personally charged a $35 fee if they fail to keep their scheduled appointment without a 24 hour notice.

Name*

First Last

Date

Signature*

I have read all terms and policies within all the pages of this packet and agree to abide by them.

Credit Card Issuer

Credit Card Number

Expiration Date

Comments

This field is for validation purposes and should be left unchanged.

Auto Accident Form

Personal Information

History of Present and Past Injuries

Other Health Information

Nature of Accident

Healthcare Services Contract

Confidentiality

Natural Substances

Emergencies

Consent to Treatment

Insurance

Arbitration

Cancelation Notice

Refunds

Authorization & Release

Notice and Claim of Health Care Provider Lien

Filing Healthcare Provider Lien

Patient Information

Med-Pay Information

Third Party Information

Attorney Information

Our Policy Regarding Cancelations

Refer a Friend

Your Friend's Info

Your Info

Your Patient's Info